Use the same article to respond to slides 4-8 for me. Thanks
ORIGINAL RESEARCH
Task Delegation and Burnout Trade-offs Among
Primary Care Providers and Nurses in Veterans
Affairs Patient Aligned Care Teams (VA PACTs)
Samuel T. Edwards, MD, MPH, Christian D. Helfrich, MPH, PhD,
David Grembowski, PhD, Elizabeth Hulen, MA, Walter L. Clinton, PhD,
Gordon B. Wood, MS, Linda Kim, PhD, MSN, RN, PHN, Danielle E. Rose, PhD,
and Greg Stewart, PhD
Purpose: Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team
members may reduce employee burnout in primary care. However, (1) the extent to which delegation
occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether
delegation is associated with burnout are all unknown.
Methods: We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in
Department of VA primary care clinics, 4 years into the VA’s patient-centered medical home initiative.
PCPs reported the extent to which they relied on other team members to complete 15 common primary
care tasks; paired nurses reported how much they were relied on to complete the same tasks. A com-
posite score of task delegation/reliance was developed by taking the average of the responses to the 15
questions. We performed multivariable regression to explore predictors of task delegation and burn-
out.
Results: Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported be-
ing relied on (PCP mean � standard deviation composite delegation score, 2.97� 0.64 [range, 1– 4];
nurse composite reliance score, 3.26 � 0.50 [range, 1– 4]). Approximately 48% of PCPs and 35% of
nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio
[OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49 – 0.78), whereas nurses who re-
ported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33–2.5).
Conclusions: Task delegation was associated with less burnout for PCPs, whereas task reliance was
associated with greater burnout for nurses. Strategies to improve work life in primary care by increas-
ing PCP task delegation must consider the impact on nurses. ( J Am Board Fam Med 2018;31:83–93.)
Keywords: Cross-sectional Studies, Patient Care Team, Patient-Centered Care, Personnel Turnover, Primary Health
Care, Professional Burnout, Veterans
Primary care involves an array of tasks including
gathering patient history, screening, evaluation, in-
tervention, health education, care coordination,
and communication with patients outside of face-
to-face visits.1– 4 An underlying objective of team-
based care models such as the patient-centered
medical home (PCMH) is the development of an
This article was externally peer reviewed.
Submitted 28 February 2017; revised 2 September 2017;
accepted 10 September 2017.
From the Section of General Internal Medicine and the
Center to Improve Veteran Involvement in Care, VA Port-
land Health Care System, Portland, OR (STE, EH); the
Division of General Internal Medicine and Geriatrics and
the Department of Family Medicine (STE), Oregon Health
& Science University, Portland; the Seattle-Denver Center
of Innovation for Veteran-Centered and Value-Driven
Care, US Department of Veterans Affairs, Seattle,
WA (CDH, WLC, GBW); the Department of Health Ser-
vices, University of Washington School of Public Health,
Seattle (CDH, DG); the VA HSR&D Center for Study of
Healthcare Innovation, Implementation & Policy, Greater
Los Angeles Health Care System, Los Angeles, CA (LK,
DER); the VISN 23 Patient Aligned Care Team Demon-
stration Laboratory, Iowa City VA Health Care System,
Iowa City, IA (GS); and the Department of Management,
University of Iowa, Iowa City (GS).
Funding: This work was supported by the Patient Cen-
tered Medical Home Demonstration Laboratory Coordina-
tion Center (XVA-61– 041) of the U.S. Department of Vet-
erans Affairs.
doi: 10.3122/jabfm.2018.01.170083 Task Delegation and Burnout Trade-offs in VA PACTs 83
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interdisciplinary team that shares primary care
tasks and allows members to work at the top of
their competence.5,6 However, differences in
power and status, as well as a lack of clarity about
who should do what, makes delegating tasks a chal-
lenge.7–9 Teams struggle with poor role clarity and
confusion over responsibility for clinical tasks.10 –15
Team struggles over who should do which tasks
may contribute to work-related burnout, a psycho-
logical state characterized by emotional exhaustion,
lack of enthusiasm, and feelings of ineffective-
ness.16,17 Burnout is common among primary care
providers (PCPs)18,19 and primary care nurses20,
with potentially negative implications for patient
satisfaction21,22, patient safety18,23,24, and employee
turnover.25 Clinical workload, unstable and inade-
quate staffing26, and performing tasks that do not
take advantage of a team members’ skills27 are as-
sociated with increased burnout. By contrast, per-
ception that a team culture exists is greater28 and
more sharing of clinical and clerical tasks29, are
associated with lower burnout among PCPs and
staff. Improving task delegation among interdisci-
plinary team members in a PCMH model may thus
reduce burnout among PCPs and staff.
In 2010, the US Department of Veterans Affairs
(VA) began implementing its PCMH model
through the Patient Aligned Care Teams (PACT)
initiative in VA primary care clinics. Within the VA
PACT model, a “teamlet” consists of 4 members: a
PCP (physician, nurse practitioner, physician assis-
tant), nurse care manager (registered nurse), clinical
associate (licensed practical nurse/licensed vocational
nurse), and administrative associate (medical assis-
tant). While guidelines were distributed describing
the role of each team member30, teams were given
substantial flexibility in determining their own work-
flows. Early in the implementation of PACT, signif-
icant differences existed between PCP’s and nurses’
perceptions of responsibility for specific clinical tasks:
PCPs reported they perform most clinical tasks alone,
whereas nurses reported they were relied on for the
same tasks.11 However, these discrepant findings may
have occurred because PCPs and nurses were sur-
veyed separately, rather than analyzing responses
from PCPs and nurses in the same team. In addition,
it remains unknown how perceived task delegation
relates to employee burnout.
In this study we surveyed PCPs and nurses 4
years into PACT implementation to examine
whether PCP and nurse perceptions of task dele-
gation were similar or different within matched
PCP-nurse dyads (ie, PCPs and nurses in the same
teamlet). We examined factors that might contrib-
ute to perceptions of task delegation and whether
task delegation was associated with employee burn-
out.
Methods
Our study is part of the national PACT Demon-
stration Laboratory Initiative efforts to support and
evaluate the VA’s transition to the PCMH model.
This study is based on the 2014 national provider
and staff survey, which was designed to assess pri-
mary care personnel’s perceptions of work condi-
tions during PACT implementation.
The survey was reviewed by national union lead-
ers through VA Labor Management Relations to
ensure that surveys were not coercive or a danger to
employees. The study was considered a quality im-
provement project by VA national primary care
leadership and was exempt from institutional re-
view board review.
Procedures and Participants
The survey was administered online from August 4
through September 1, 2014, using Inquisit software
(Millisecond Software, Seattle, WA). A survey link
was sent via E-mail to national VA primary care
leadership, who disseminated it to leaders of the
regional networks and local facilities with a request
for them to distribute the link to local primary care
personnel. Three E-mail reminders were sent, and
no incentives were used. The survey asked respon-
dents to self-identify using a nationally designated
primary care team identifier; the completed surveys
did not include individual identifiers. Because the
survey was disseminated electronically through
leadership channels, we do not know the exact
number of eligible employees who were contacted;
that is, we do not have a true denominator with
which to calculate a response rate. We estimated
the individual response rate to be 21% based on the
number of providers (physicians, nurse practitio-
Conflict of interest: none declared.
Corresponding author: Samuel T. Edwards, MD, MPH,
Section of General Internal Medicine, VA Portland Health
Care System, 3710 SW US Veterans Hospital Rd.
(R&D199), Portland, OR 97239 �E-mail: samuel.edwards@
va.gov�.
84 JABFM January–February 2018 Vol. 31 No. 1 http://www.jabfm.org
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ners, and physician assistants) who responded rel-
ative to the number of providers in a panel man-
agement database during the same period, which
was the most reliable administrative data on per-
sonnel nationally. Administrative records indicated
that 8114 primary care teamlets existed in the VA at
the time of our survey; 2809 teamlets had at least 1
respondent and 20.9% of active PCPs returned
surveys. Our sample consisted of 721 PCPs and 598
nurses, who together compromised 777 PCP-nurse
dyads in 554 teamlets.
Study Measures
Employee Perceptions of Task Delegation/Reliance
and Discordance
We asked PCPs and nurses about how 15 common
primary care tasks (Table 1) were performed. We
asked PCPs, “To what extent do you rely on your
teamlet to accomplish the following primary care
activities?” We asked nurses, “To what extent does
your teamlet/clinic team rely on you to accomplish
the following primary care activities?” PCPs and
nurses responded on a 4-point scale for each task:
“not at all” (1), “slightly” (2), “somewhat” (3), or “a
great deal” (4). We defined these measures as “task
delegation” for PCPs and “task reliance” for nurses.
We calculated the absolute value of the difference
between PCP task reliance and nurse task reliance
for each dyad; this was defined as “task discor-
dance.” Two clinician researchers grouped the 15
tasks into 5 categories based on exploratory factor
analysis and clinical experience. The task questions
were developed by clinicians and social scientists
with experiencing practicing and studying primary
care at the VA, and the questions have been used in
several published studies.11,31,32
Composite Task Delegation/Reliance Score
To generate a composite task delegation/reliance
score, we calculated the mean of the scores for all
respondents across all 15 tasks. We also calculated
the mean task delegation/reliance score for each
task and task grouping.
Burnout
Burnout was measured by a single item, a 5-point
measure used in the Physician Worklife Study and
several other large studies of burnout among phy-
sicians in the United States.33,34 The specific ques-
tion is, “Overall, based on your definition of burn-
out, how would you rate your level of burnout?”
Responses were scored on a 5-category ordinal
scale: 1 � “I enjoy my work. I have no symptoms of
burnout”; 2 � “Occasionally I am under stress, and
I do not always have as much energy as I once did,
but I do not feel burned out”; 3 � “I am definitely
burning out and have 1 or more symptoms of burn-
out, such as physical and emotional exhaustion”;
4 � “The symptoms of burnout that I am experi-
encing will not go away. I think about frustration at
work a lot”; and 5 � “I feel completely burned out
and often wonder if I can go on. I am at the point
where I may need some changes or may need to
seek some sort of help.” This question has been
validated previously against the Emotional Exhaus-
tion Subscale of the Maslach Burnout Inven-
Table 1. Primary Care Tasks and Task Groupings
Task Task Groupings
Gathering patient preventive services history (eg, immunization history) In-person data collection
Screening patients for diseases (eg, doing a depression screen)
Assessing patient lifestyle factors (eg, diet, smoking cessation)
Receiving messages from patients (other than requests for prescriptions) Messaging
Resolving messages from patients (other than requests for prescriptions)
Responding to prescription refill requests
Encouraging lifestyle modifications (eg, diet, smoking cessation) Counseling/education
Educating patients about disease-specific self-care activities (eg, foot care in diabetes)
Educating patients about medications
Evaluating patients and making treatment decisions Decision making
Completing forms for patients (eg, disability documentation)
Responding to requests for home health care orders
Responding to patient diagnostic and treatment data (eg, laboratory tests, radiology studies) Tracking data
Following up on referrals (eg, to specialists)
doi: 10.3122/jabfm.2018.01.170083 Task Delegation and Burnout Trade-offs in VA PACTs 85
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tory.26,33,35 Consistent with previous analyses, a
score �3 was considered burnout.31
Staffing, Coaching, Huddles, and Tenure at the VA
Other independent variables from the survey in-
cluded perception of adequate staffing (“Is your
PACT staffed at the recommended 3 FTE [full-
time equivalent] team members to each PCP
FTE?” [yes � 1/no � 0]), perception of recent staff
turnover (“Has your teamlet had any changes in or
loss of staff in the past 12 months?” [yes � 1/no �
0]), minutes spent in huddles (“Thinking about a
typical day in your primary care clinic, about how
much time do you spend on meeting with your
teamlet/clinic to discuss patient care [eg, in hud-
dles]?” [do not huddle (coded as 0 minutes), �5
minutes (coded as 2.5 minutes), 6 to 10 minutes
(coded as 8 minutes), 11 to 20 minutes (coded as
15.5 minutes), 21 to 30 minutes (coded as 25.5
minutes), �30 minutes (coded as 30 minutes)]),
presence of a PACT coach (“Did your PACT have
a coach?” [yes � 1/no � 0]), and duration of VA
employment (“How long have you worked for the
Veterans Health Administration?” [�6 months
(coded as 3 months), 6 months to 1 year (coded as
9 months), 1 to 2 years (coded as 18 months), 2 to
5 years (coded as 42 months), 5 to 10 years (coded
as 90 months), 10 to 15 years (coded as 150
months), 15 to 20 years (coded as 210 months),
�20 years (coded as 240 months)]).
Statistical Analysis
We reviewed summary statistics to describe char-
acteristics of the sample and to compare task dele-
gation/reliance and burnout in PCPs and nurses.
Because the composite task delegation/reliance
score had a range of noninteger values, we used it as
a continuous variable in regression models. We
performed linear regression to test the association
between independent variables and composite task
delegation/reliance. We performed multivariable
logistic regression to explore associations with
burnout at the respondent level. Because some dy-
ads came from the same teamlets (ie, some nurses
worked with �1 PCP), we used GLIMMIX to
account for teamlet-level effects. All analyses were
performed using SAS 7.3 (SAS Institute Inc., Cary,
NC). Sensitivity analyses were performed to ensure
that missing data for some survey items did not
affect the overall findings.
Results
Among 777 PCP-nurse dyads, mean composite
task delegation among PCPs was 2.97 (standard
deviation [SD], 0.64; range, 1– 4) and mean com-
posite task reliance among nurses was 3.26 (SD,
0.50; range, 1– 4) (Table 2). Among task subgroups,
PCPs reported delegating more for messaging tasks
(mean, 3.47) and in-visit data collection (mean,
3.31), and reported delegating less for tracking data
(mean, 2.48) and decision making (mean, 2.53).
Nurses reported being relied on more than PCPs
reported delegating for messaging (mean, 3.66),
counseling/education (mean, 3.60), and in-visit
data collection (mean, 3.40). The mean (SD) dyad-
level task discordance was 0.91 (0.43) overall, but it
was highest for decision making (mean, 1.14; SD,
0.62) and tracking data (mean, 1.17; SD, 0.79).
A total of 48% of PCPs and 35% of nurses
reported burnout (Table 2). Approximately two
thirds of respondents reported appropriate staffing
(PCPs, 64.3%; nurses, 66.4%), and just over half
reported recent staff turnover in their clinic (PCPs,
54.4%; nurses, 54.9%). Mean huddle time was ap-
proximately 14 minutes, and about half of respon-
dents reported the presence of a PACT coach.
Mean duration of VA employment was just over 8.5
years.
Appropriate staffing was associated with higher
composite task delegation for PCPs (� � 0.179;
P � .01) but was associated with lower composite
task reliance for nurses (� � �0.119; P � .01)
(Table 3). Greater staff turnover was associated
with reduced composite task delegation for PCPs
(� � �0.123; P � .02) but was not associated with
composite nurse task reliance. Increased huddle
time was associated with higher composite task
delegation for both PCPs (� � 0.014; P � .01) and
nurses (� � 0.006; P � .01).
Table 4 shows associations of composite task
delegation/reliance and other team member and
clinic characteristics with burnout. For PCPs,
greater composite task delegation was associated
with less burnout (odds ratio [OR], 0.62 per unit of
composite task delegation; 95% confidence interval
[CI], 0.49 – 0.78). Among nurses, however, greater
composite task reliance was associated with more
burnout (OR, 1.83; 95% CI, 1.33–2.5). In multi-
variable analysis appropriate staffing was negatively
associated with burnout for PCPs and nurses,
whereas staff turnover and duration of VA employ-
86 JABFM January–February 2018 Vol. 31 No. 1 http://www.jabfm.org
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ment were positively associated with PCP and
nurse burnout. Presence of a PACT coach was
associated with significantly lower burnout for
PCPs only (OR, 0.62; 95% CI, 0.44 – 0.86).
Table 4 also shows the associations of task dis-
cordance and clinic/respondent characteristics with
burnout. Dyad-level task discordance, the difference
between perceived PCP task delegation and nurses’
reliance, was associated with burnout for PCPs (OR,
1.77; 95% CI, 1.27–2.47) but not for nurses.
Discussion
We observed several notable findings in this na-
tional cross-sectional study of task delegation and
burnout among VA PCP-nurse dyads. First,
PCPs reported delegating tasks less than nurses
reported being relied on. Second, while increased
huddle time was associated with greater task del-
egation for both PCPs and nurses, appropriate
staffing was associated with greater task delega-
tion for PCPs and less perceived task reliance for
Table 2. Perceived Task Delegation/Reliance and Prevalence of Burnout among Veterans Affairs Primary Care
Providers and Nurse Care Managers
PCPs
(n � 721)
Nurses
(n � 598) Difference P Value
Composite task delegation/reliance (15 tasks) 2.97 (0.64) 3.26 (0.50) 0.91 (0.43) �.01
In-visit data collection 3.31 (0.71) 3.40 (0.66) 0.80 (0.63) �.01
Messages 3.47 (0.62) 3.66 (0.56) 0.62 (0.60) �.01
Counseling/education 3.05 (0.82) 3.60 (0.53) 0.85 (0.68) �.01
Decision making 2.53 (0.86) 2.76 (0.85) 1.14 (0.62) �.01
Tracking data 2.48 (1.01) 2.99 (0.91) 1.17 (0.79) �.01
Burnout
Dichotomized 48.6 34.8 �.01
5-Level categorization
1 13.0 23.3
2 38.5 42.0
3 29.0 21.5
4 12.5 8.6
5 7.1 4.6 �.01
Appropriate staffing 64.3 66.4 .06
Turnover 54.4 54.9 .60
Minutes spent in huddles, mean (SD) 13.30 (10.90) 14.33 (11.61) .40
Presence of PACT coach 45.3 50.6 .06
Years of VA employment, mean (SD) 8.53 (6.37) 8.61 (6.90) .13
Data are mean (standard deviation) or percentages.
PACT, patient aligned care team; PCP, primary care provider; SD, Standard Deviation; VA, Veterans Affairs.
Table 3. Multivariable Regression Examining Association of Reported Staffing, Turnover, Huddle Time, Presence
of Patient Aligned Care Team Coach, and Length of Veterans Affairs Employment, with a Composite Task
Delegation/Reliance Score
PCPs Nurses
� P Value � P Value
Appropriate staffing 0.179 �.01 �0.119 .01
Staff turnover �0.123 .02 0.013 .77
Minutes in huddle 0.012 �.01 0.006 �.01
Presence of PACT coach �0.005 .92 �0.026 .55
Years at VA 0.004 .35 0.005 .13
PACT, patient aligned care team; PCP, primary care provider; VA, Veterans Affairs.
doi: 10.3122/jabfm.2018.01.170083 Task Delegation and Burnout Trade-offs in VA PACTs 87
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nurses. Finally, increased delegation of tasks was
associated with lower burnout for PCPs, but in-
creased task reliance reported by nurses was as-
sociated with increased burnout. Dyad-level task
discordance was associated with burnout for
PCPs only.
The ongoing workforce shortage in primary
care has led to urgent calls to make the practice of
primary care more rewarding for clinicians, with
the hope that this will increase the number of
trainees who choose careers in primary care and
retain PCPs currently in practice.36 One often-
cited means to improve the worklife of PCPs is
sharing the workload by having them delegate rou-
tine tasks to other team members, thereby allowing
them to focus on clinical care of patients. This
study demonstrates that PCPs who report more
frequent delegation of tasks to their primary care
staff do indeed report less burnout. This is an
encouraging finding, suggesting that efforts to im-
prove task delegation may improve work life for
PCPs.
However, nurses who perceived a high level of
reliance for tasks also reported more burnout. This
suggests that nurses may perceive task delegation as
simply increasing their workload, which is a key
contributor to burnout.17 Because nurses have a
broad scope of practice, they can perform a wide
range of tasks. When PCPs are unsure of which
team member should be doing a given task, dele-
gating to a nurse may become a default. This issue
could be exacerbated by inadequate staffing at the
administrative associate levels. Such inefficient del-
egation is consistent with our findings: We ob-
served that, among nurses, perceived task reliance
was higher in teams that were not fully staffed,
suggesting that tasks cannot be delegated to other
team members.
Task discordance, the dyad-level difference in
perceptions of task delegation between PCPs and
nurses, was associated with burnout for PCPs but
not for nurses. Task discordance could reflect a
communication problem that is more frustrating
for PCPs. Alternatively, as nurses report high
levels of task reliance for all tasks,11 this discor-
dance could be driven by PCP responses and as
such is more reflective of PCPs’ levels of task
delegation.
Ideally, with training, coaching, and team hud-
dles, the appropriate roles of each team member are
individually negotiated and agreed upon, so that
tasks are delegated appropriately, minimizing over-
load on any 1 team member. It is encouraging to
note that increased huddle time was associated with
increased task delegation for both PCPs and
nurses. In addition, among PCPs, the presence of a
PACT coach was associated with increased task
delegation, suggesting that practice facilitation has
an important role in assisting teams to appropri-
ately assign work among team members.
Inadequate staffing and recent staff turnover
were strongly associated with burnout for both
Table 4. Association of Composite Task Delegation/Reliance and Composite Task Discordance, Along with Staffing,
Turnover, Huddle Time, Patient Aligned Care Team Coach, and Length of Veterans Affairs Employment, with
Workplace Burnout
PCP Burnout Nurse Burnout
OR 95% CI OR 95% CI
Composite task delegation/reliance (15 tasks) 0.68 0.49–0.93 1.66 1.13–2.45
Appropriate staffing 0.68 0.46–0.99 0.68 0.46–1.00
Staff turnover 1.74 1.20–2.52 1.42 0.98–2.07
Minutes in huddle 0.98 0.96–1.00 1.00 0.98–1.02
Presence of PACT coach 0.68 0.47–0.98 0.83 0.57–1.19
Years at VA 1.05 1.02–1.08 1.00 0.97–1.03
Composite task discordance (15 tasks) 1.81 1.14–2.88 1.26 0.84–1.91
Appropriate staffing 0.68 0.46–0.99 0.65 0.44–0.95
Turnover 1.83 1.27–2.65 1.42 0.98–2.06
Huddle time 0.98 0.96–0.99 1.00 0.99–1.02
PACT coach present 0.68 0.47–0.98 0.83 0.58–1.19
Years at VA 1.05 1.02–1.08 1.00 0.98–1.03
CI, confidence interval; OR, odds ratio; PACT, patient aligned care team; PCP, primary care provider; VA, Veterans Affairs.
88 JABFM January–February 2018 Vol. 31 No. 1 http://www.jabfm.org
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PCPs and nurses, as has been shown previously.26
Developing functional team relationships that al-
low for effective team-based task delegation re-
quires a fully staffed PACT team and adequate time
spent working together to learn how to maximize
each team member’s skill set. Without well-staffed,
trained, and stable teams, the complex job of effi-
ciently sharing work among a primary care teamlet
may be impossible.
A particular challenge in sharing work across a
primary care team is that many essential primary
care tasks may be perceived as unrewarding and
contributing to burnout. For example, requesting
outside records, sending patients normal laboratory
test results or calling in updated home health or-
ders can feel like rote busywork, even though such
tasks are important in providing coordinated care.
Because PCPs often want to delegate these tasks, it
is important to ensure that delegation does not
exacerbate burnout for other team members. As
described above, 1 solution is to make sure that
teams are adequately staffed to prevent nurses from
being asked to perform tasks that other team mem-
bers are qualified to do. Another avenue is to make
sure that all team members share in meaningful,
rewarding work with transparent results.29 For ex-
ample, developing longitudinal relationships with
patients can greatly increase providers’ sense of
purpose in their jobs,37 and this role could be
shared across the team. Clinic leadership could also
stress the critical contributions of all team members
and the importance of all team members’ work to
patient health.
This study has several limitations. First, we re-
lied on a single-item measure of burnout, whereas
the Maslach Burnout Inventory separately mea-
sures the 3 dimensions of burnout: emotional ex-
haustion, lack of enthusiasm, and feelings of inef-
fectiveness. However, this single-item measure has
been used previously38 and shows strong correla-
tion with the emotional exhaustion subscale of the
Maslach Burnout Inventory.33 Second, as a cross-
sectional survey, we cannot make conclusions re-
garding causation, only association. With subse-
quent surveys of VA PCPs and staff, we may be able
to study how changes in task delegation affect
burnout over time. Unfortunately, the current sur-
vey was anonymous, which prevents the tracking of
individual respondents. Third, the survey had a
low individual response rate, risking that the
sample is not representative of all VA primary
care clinicians and staff. Nevertheless, our sam-
ple of 777 PCP-nurse dyads represents a large
sample of PCPs and nurses who work together
directly, in which perceptions of work responsi-
bility can be directly compared. Fourth, we only
examined perceptions of PCPs and nurses, al-
though PACT teams also include other roles, and
delegation can occur among all team members.
Finally, although the tasks we chose are com-
monly performed by primary care teams, our list
is not comprehensive.
Conclusion
We demonstrate that in PCP-nurse dyads from
teamlets, perceived task delegation is associated
with less reported burnout for PCPs but more
burnout for nurses, suggesting that efforts to
reduce burnout among PCPs by delegating work
to nurses may inadvertently increase burnout
among those nurses. Guidelines for task delega-
tion within a teamlet should be developed to
reduce the likelihood of burnout among nurses.
To see this article online, please go to: http://jabfm.org/content/
31/1/83.full.
References
1. Hysong SJ, Best RG, Moore FI. Are we under-
utilizing the talents of primary care personnel? A job
analytic examination. Implement Sci 2007;2(1):10.
2. Wetterneck TB, Lapin JA, Krueger DJ, Holman
GT, Beasley JW, Karsh B-T. Development of a
primary care physician task list to evaluate clinic visit
workflow. BMJ Qual Saf 2012;21:47–53.
3. Holman GT, Beasley JW, Karsh BT, Stone JA,
Smith PD, Wetterneck TB. The myth of standard-
ized workflow in primary care. J Am Med Inform
Assoc 2016;23:29 –37.
4. Stange KC, Zyzanski SJ, Jaen CR, et al. Illuminat-
ing the “black box”. A description of 4454 patient
visits to 138 family physicians. Fam Pract 1998;46:
377– 89.
5. Altschuler J, Margolius D, Bodenheimer T, Grumbach
K. Estimating a reasonable patient panel size for pri-
mary care physicians with team-based task delegation.
Ann Fam Med 2012;10:396 – 400.
6. Green LV, Savin S, Lu Y. Primary care physician
shortages could be eliminated through use of teams,
nonphysicians, and electronic communication. Health
Aff (Millwood) 2013;32:11–9.
7. Bowling A. Delegation to nurses in general practice.
J R Coll Gen Pract 1981;31:485–90.
8. Bosley S, Dale J. Healthcare assistants in general
practice: practical and conceptual issues of skill-mix
change. Br J Gen Pract 2008;58:118 –24.
doi: 10.3122/jabfm.2018.01.170083 Task Delegation and Burnout Trade-offs in VA PACTs 89
co
p
yrig
h
t.
o
n
1
4
Ja
n
u
a
ry 2
0
2
2
b
y g
u
e
st. P
ro
te
cte
d
b
y
h
ttp
://w
w
w
.ja
b
fm
.o
rg
/
J A
m
B
o
a
rd
F
a
m
M
e
d
: first p
u
b
lish
e
d
a
s 1
0
.3
1
2
2
/ja
b
fm
.2
0
1
8
.0
1
.1
7
0
0
8
3
o
n
1
2
Ja
n
u
a
ry 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
http://jabfm.org/content/31/1/83.full
http://jabfm.org/content/31/1/83.full
http://www.jabfm.org/
9. Giannitrapani KF, Soban L, Hamilton AB, et al.
Role expansion on interprofessional primary care
teams: barriers of role self-efficacy among clinical
associates. Healthc (Amst) 2016;4:321– 6.
10. True G, Stewart GL, Lampman M, Pelak M,
Solimeo SL. Teamwork and delegation in medical
homes: primary care staff perspectives in the Veter-
ans Health Administration. J Gen Intern Med 2014;
29(Suppl 2):S632–9.
11. Edwards ST, Rubenstein LV, Meredith LS, et al.
Who is responsible for what tasks within primary
care: perceived task allocation among primary care
providers and interdisciplinary team members.
Healthc (Amst) 2015;3:142–9.
12. Aita V, Dodendorf DM, Lebsack JA, Tallia AF,
Crabtree BF. Patient care staffing patterns and roles
in community-based family practices. Fam Pract
2001;50:889.
13. Grace SM, Rich J, Chin W, Rodriguez HP. Imple-
menting interdisciplinary teams does not necessarily
improve primary care practice climate. Am J Med
Qual 2016;31:5–11.
14. Dini L, Sarganas G, Boostrom E, Ogawa S, Heintze
C, Braun V. German GPs’ willingness to expand
roles of physician assistants: a regional survey of
perceptions and informal practices influencing up-
take of health reforms in primary health care. Fam
Pract 2012;29:448 –54.
15. Rodriguez HP, Giannitrapani KF, Stockdale S,
Hamilton AB, Yano EM, Rubenstein LV. Teamlet
structure and early experiences of medical home im-
plementation for veterans. J Gen Intern Med 2014;
29(Suppl 2):S623–31.
16. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Sil-
ber JH. Hospital nurse staffing and patient mortality,
nurse burnout, and job dissatisfaction. JAMA 2002;
288:1987–93.
17. Maslach C, Jackson SE. The measurement of expe-
rienced. J Occup Behav 1981;2:99 –113.
18. Shanafelt TD, Boone S, Tan L, et al. Burnout and
satisfaction with work-life balance among US physi-
cians relative to the general US population. Arch
Intern Med 2012;172:1377– 85.
19. Puffer JC, Knight C, O’Neill TR, et al. Prevalence
of burnout in board certified family physicians. J Am
Board Fam Med 2017;30:125– 6.
20. McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane
DM, Aiken LH. Nurses’s widespread job dissatisfac-
tion, burnout, and frustration with health benefits
signal problems for patient care. Health Aff (Mill-
wood) 2011;30:202–10.
21. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary
PD, Brennan TA. Is the professional satisfaction of
general internists associated with patient satisfac-
tion? J Gen Intern Med 2000;15:122– 8.
22. Halbesleben JR, Rathert C. Linking physician burn-
out and patient outcomes: exploring the dyadic rela-
tionship between physicians and patients. Health
Care Manage Rev 2008;33:29 –39.
23. Spence Laschinger HK, Leiter MP. The impact of
nursing work environments on patient safety out-
comes: the mediating role of burnout/engagement. J
Nurs Adm 2006;36:259 – 67.
24. West CP, Huschka MM, Novotny PJ, et al. Associ-
ation of perceived medical errors with resident dis-
tress and empathy: a prospective longitudinal study.
JAMA 2006;296:1071– 8.
25. Landon BE, Reschovsky JD, Pham HH, Blumenthal
D. Leaving medicine: the consequences of physician
dissatisfaction. Med Care 2006;44:234 – 42.
26. Helfrich CD, Simonetti JA, Clinton WL, et al. The
association of team-specific workload and staffing
with odds of burnout among VA primary care team
members. J Gen Intern Med 2017;32:760 – 6.
27. Ladebue AC, Helfrich CD, Gerdes ZT, Fihn SD,
Nelson KM, Sayre GG. The experience of Patient
Aligned Care Team (PACT) members. Health Care
Manage Rev 2016;41:2–10.
28. Willard-Grace R, Hessler D, Rogers E, Dube K,
Bodenheimer T, Grumbach K. Team structure and
culture are associated with lower burnout in primary
care. J Am Board Fam Med 2014;27:229 –38.
29. Sinsky CA, Willard-Grace R, Schutzbank AM,
Sinsky TA, Margolius D, Bodenheimer T. In
search of joy in practice: a report of 23 high-
functioning primary care practices. Ann Fam Med
2013;11:272– 8.
30. Department of Veterans Affairs. Analyzing tasks
for the patient centered medical home. Available
from: http://www.va.gov/HEALTH/services/pri-
marycare/pact/resources.asp. Accessed November
15, 2017.
31. Helfrich CD, Dolan ED, Simonetti J, et al. Elements
of team-based care in a patient-centered medical
home are associated with lower burnout among VA
primary care employees. J Gen Intern Med 2014;
29(Suppl 2):659 – 66.
32. Nelson KM, Helfrich C, Sun H, et al. Implementa-
tion of the patient-centered medical home in the
Veterans Health Administration: associations with
patient satisfaction, quality of care, staff burnout, and
hospital and emergency department use. JAMA In-
tern Med 2014;174:1350 – 8.
33. Dolan ED, Mohr D, Lempa M, et al. Using a single item
to measure burnout in primary care staff: a psychometric
evaluation. J Gen Intern Med 2015;30:582–7.
34. Williams ES, Konrad TR, Linzer M, et al. Physician,
practice, and patient characteristics related to pri-
mary care physician physical and mental health: re-
sults from the Physician Worklife Study. Health
Serv Res 2002;37:121– 43.
35. Rohland BM, Kruse GR, Rohrer JE. Validation of a
single-item measure of burnout against the Maslach
Burnout Inventory among physicians. Stress Health
2004;20:75–9.
90 JABFM January–February 2018 Vol. 31 No. 1 http://www.jabfm.org
co
p
yrig
h
t.
o
n
1
4
Ja
n
u
a
ry 2
0
2
2
b
y g
u
e
st. P
ro
te
cte
d
b
y
h
ttp
://w
w
w
.ja
b
fm
.o
rg
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m
B
o
a
rd
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m
M
e
d
: first p
u
b
lish
e
d
a
s 1
0
.3
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2
2
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b
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0
1
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.0
1
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7
0
0
8
3
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n
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2
Ja
n
u
a
ry 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
http://www.va.gov/HEALTH/services/primarycare/pact/resources.asp
http://www.va.gov/HEALTH/services/primarycare/pact/resources.asp
http://www.jabfm.org/
36. Bodenheimer T, Sinsky C. From triple to quadruple
aim: care of the patient requires care of the provider.
Ann Fam Med 2014;12:573– 6.
37. Beach MC, Inui T; Relationship-Centered Care
Research Network. Relationship-centered care. A
constructive reframing. J Gen Intern Med 2006;
21(Suppl 1):S3– 8.
38. Linzer M, Manwell LB, Williams ES, et al. Working
conditions in primary care: physician reactions and care
quality. Ann Intern Med 2009;151:28 –36, W6 –9.
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Appendix Table 1. Perceived Delegation and Reliance of Individual Tasks for Primary Care Physicians and Nurses
PCPs
(n � 721)
Nurses
(n � 598) P Value
Gathering patient preventive services utilization history (eg,
immunization history)
3.33 (0.92) 3.30 (0.89) .73
Screening patients for diseases (eg, doing a depression screen) 3.35 (0.90) 3.30 (0.91) .85
Assessing patient lifestyle factors 3.25 (0.84) 3.60 (0.65) �.01
Receiving messages from patients 3.70 (0.60) 3.75 (0.58) .08
Resolving messages from patients (other than requests for
prescriptions)
3.49 (0.73) 3.72 (0.62) �.01
Responding to prescription refill requests 3.06 (1.04) 3.51 (0.75) �.01
Encouraging lifestyle modifications 3.17 (0.88) 3.70 (0.56) �.01
Educating patients about disease-specific self-care activities
(eg, foot care in diabetes)
3.11 (0.94) 3.63 (0.65) �.01
Educating patients about medications 2.87 (0.97) 3.47 (0.76) �.01
Evaluating patients and making treatment decisions 2.64 (1.02) 2.91 (1.10) �.01
Completing forms for patients 2.20 (1.11) 2.41 (1.11) �.01
Responding to requests for home health care orders 2.67 (1.12) 2.69 (1.14) 0.40
Responding to patient diagnostic and treatment data (eg,
laboratory tests, radiology studies)
2.58 (1.10) 3.00 (1.03) �.01
Following-up on referrals (eg, to specialists) 2.49 (1.09) 2.95 (1.02) �.01
PCPs, primary care providers.
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Appendix Table 2. Association of Task Delegation/Reliance with Burnout, by Task Groupings and Individual Tasks,
Adjusting for Other Covariates*
PCP Burnout Nurse Burnout
In-visit data collection 0.90 (0.66–1.21) 1.09 (0.83–1.44)
Gathering patient preventive services utilization
history (eg, immunization history)
1.02 (0.81–1.28) 0.88 (0.72–1.08)
Screening patients for diseases (eg, doing a
depression screen)
1.04 (0.83–1.31) 0.92 (0.75–1.12)
Assessing patient lifestyle factors 0.76 (0.59–0.96) 1.02 (0.77–1.35)
Messages 0.75 (0.54–1.04) 0.95 (0.68–1.32)
Responding to prescription refill requests 0.75 (0.62–0.91) 1.39 (1.07–1.80)
Receiving messages from patients 0.93 (0.67–1.29) 1.46 (1.00–2.13)
Resolving messages from patients (other than
requests for prescriptions)
1.05 (0.79–1.39) 1.38 (0.99–1.93)
Counseling/education 0.70 (0.55–0.90) 0.94 (0.66–1.33)
Encouraging lifestyle modifications 0.77 (0.61–0.97) 1.04 (0.76–1.43)
Educating patients about disease-specific self-care
activities (eg, foot care in diabetes)
0.82 (0.67–1.02) 0.82 (0.62–1.09)
Educating patients about medications 0.73 (0.60–0.90) 1.34 (1.03–1.75)
Decision making 0.77 (0.61–0.96) 0.91 (0.73–1.13)
Evaluating patients and making treatment decisions 0.81 (0.68–0.97) 1.27 (1.06–1.51)
Completing forms for patients 0.86 (0.73–1.01) 1.21 (1.03–1.43)
Responding to requests for home health care orders 0.94 (0.79–1.11) 1.24 (1.05–1.47)
Responding to patient diagnostic and treatment
data (eg, laboratory tests, radiology studies)
0.81 (0.68–0.96) 1.20 (1.00–1.44)
Tracking data 0.88 (0.73–1.06) 0.94 (0.76–1.15)
Tracking patient diagnostic data 0.87 (0.73–1.03) 1.14 (0.95–1.37)
Following up on referrals (eg, to specialists) 0.95 (0.80–1.13) 1.45 (1.20–1.76)
Data are adjusted odds ratios (95% confidence intervals).
*Model also includes appropriate staffing, recent turnover, presence of Patient Aligned Care Team coach, and duration of Veterans
Affairs employment.
PCPs, primary care providers.
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Improving
Hand-off
Report
Student Names
Team Name and First/Last Names of Participants
Problem
Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Our task is to propose a change that will address these issues.
Report (timing and hand off errors: Unit managers observed that there was miscommunication between staff during shift report. Often times leaving out important patient information as well as taking a significant amount of time to relay the information. Our goal it to offer a change that will address these issues.
Now here is our SWOT analysis starting off with Derrick talking about the strengths.
Majka
“Communication failures compromise patient treatment, care quality, and safety. It also leads to medical errors, the third leading cause of deaths in the United States” (Ghosh, et all., 2015)
“The varying parties and large amount of complex information included in patient handoff reports frequently contribute to informational gaps and omissions in the handoff report that can lead to sentinel events and patient hard” (Staggers & Blaz, 2013)
“Research has identifed handovers as a risky time in the care process, when information may be lost, distorted or misinterpreted (Borowitz et al 2008, Owen et al. 2009, Philibert 2009)
Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Your task is to propose a change that will address these issues.
Increase of errors during patient hand-off report leading to missed information and incomplete tasks
Hand-off report time is taking a greater deal of time
Our task is to implement the use of SBAR as the standard hand-off report between shifts in order to reduce errors and decrease the time spent giving report.
2
SWOT
Strengths:
Multidepartment focus addressing handoff report problems(Robins et al., 2017)
Solutions shorten time taken in report while increasing quantity of pertinent information. (Stewart & Hand, 2017)
SBAR is supported by the Joint Commision (Stewart & Hand, 2017)
Proven error reduction due to use of SBAR tool. (Stewart & Hand, 2017)
SBAR is an evidence-based hand-off tool (Eberhardt, 2014)
Weakness
Use of the tool requires education to reduce user error (Stacey Eberhardt 2014)
Medical personnel have personal bias on giving report (Ghosh et al., 2018)
Some staff are unreceptive to change (Robins & Dai, 2017).
Evaluating execution of report can be affected by observer bias (Robins & Dai, 2017)
Opportunities
SBAR is inexpensive as a tool and will earn its cost in education by the reduction of sentinel events (Stewart, 2017)
Improve patient handoff by implementing an evidence-based handoff tool in SBAR format (Eberhardt, 2014)
For continued nursing education in standardizing hand-off report (Ghosh et al., 2018). Threats
Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).
Some staff are unreceptive to change (Robins et al., 2017).
Evaluating execution of report is subject to observer bias (Drach-Zahavy, 2014)
Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017)
Strengths:
Multidepartment focus on addressing problems with handoff report (Robins et al., 2017)
Solutions manage to shorten time taken to give report while increasing the amount of pertinent information given in that time frame. (Stewart & Hand, 2017)
SBAR is supported by the Joint Commision (Stewart & Hand, 2017)
Error reduction due to use of SBAR tool. (Stewart & Hand, 2017)
SBAR is an evidence-based hand-off tool (Eberhardt, 2014)
Weakness (Wendy)
Use of the tool requires education for all staff to reduce user error (Stacey Eberhardt 2014)
Medical personnel have personal bias on how they want to give report (Ghosh et al., 2018)
Healthcare worker disinterest in changing how they give report. (Robins et al., 2017).
Subjective approach to measuring a handover’s strategies might be subject to bias, as participants may behave differently in the presence of an observer.
Opportunities (ashley)
SBAR is inexpensive as a tool and will earn its cost in education by providers by the reduction of sentinel events (each of which carries a high expense). (Stewart, 2017)
Improve patient handoff by implementing an evidence-based handoff tool in Situation Background Assessment Recommendation (SBAR) format (Eberhardt, 2014)
For continued nursing education in standardizing hand-off report (Ghosh et al., 2018).
Threats (Alma)
Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).
The acuity of patient injury and medical history can increase the amount of time for patient hand-off (Robins, 2017).
Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017) and sample size of 200 handovers in 5 wards in another study(Drach-Zahavy, 2014)
3
Assessment
Inefficient communication during hand off report is a challenge to patient care. (Ghosh, et al., 2018)
Communication error given during report increases risk of poor patient outcomes. (Stewart, 2017)
Hand off communication between medical personnel leads to an increase in medication errors, incomplete tasks, disorder, and eventually poor patient outcomes (Robins et al., 2015)
According to The Joint Commission, communication errors have been among the top three leading root causes of reported sentinel events every year since 2004. (Stewart, 2017)
The information we had gathered from our assessment on giving report overall was –
1. Poor communication leads to poor patient outcome
2. The Joint Commission has stated communication errors has been the top 3 leading root causes of unanticipated major events in the healthcare setting that results in death or serious physical or psychological injury to a client which require immediate investigation by the health care facility since 2004
3. And now we will be talking about our Diagnosis.
Goal should comes from assessments (SMART (MEASURABLE))
Assessment will be bullet points of why is this a problem
Specific, measurable, attainable, realistic, timely
All RNs and assistive personnel will attend 1 or more in-services on the use of SBAR handoff report within three weeks.
During the same three week period, charge nurses and nursing management will include SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.
Following the three week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of 1 month with the goal of receiving ideas of how we can improve it from the staff at the end of the 1 month period.
At the end of the one month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas they have to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the 1 month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinal events, falls, nosocomial infections, et al will be compared between the two systems.
Majka
4
Diagnosis
Lack of standardization in report
Communication Barriers (Stewart & Hand, 2017)
Communication practices learned by various career stages of nurses (promise, momentum, harvest)
Different individual communication styles
Gaps in knowledge regarding lack of standardized reporting
A lack of standardization in report increases risk of error and poor patient outcomes
5
S.M.A.R.T. Goal
Use an evidence-based standardized hand-off report tool to reduce report times to less than 45 minutes while reducing report-based errors by 20% within 6-month period.
Precontempemplation: Nurse manager goes to charge nurses, harvest nurses, and harvest support staff with the SBAR template and asks them to sit with it for one week. He or she will ask for feedback from these individuals about implementing it on the unit.
Contemplation: Harvest nurses and support staff, and charge nurses spend a week with the SBAR template and consider its strengths, weaknesses, and or simply form an opinion around it.
Preparation: nurse manager introduces in-services on SBAR and charge nurses begin introducing the template during pre-shift meetings.
Action: Nurses and support staff begin using the template during all hand-off reports for a one month period. Nurse manager seeks input from harvest staff on ways to improve the system and attempts to include their input on a trial period, thereby extending the practice of the original SBAR for another month with most staff, and offering a personalization to those interested in improving the system.
Maintenance: Nurse manager compares statistics from the same time period one year ago, to the same length of time prior to using the SBAR report, and the data from the SBAR report compared with the modified SBAR report and presents the data to the staff at a staff meeting. At the meeting the nurse manager encourages public input and opinions on the SBAR report. If there is resistance, the manager asks that SBAR be continued in practice for a 3 month period in which he or she will personally receive report from individuals on their patients – helping those nurses who need it with ways to be more succinct. At this point, the report will have been used in practice for 5 months and will have become habit for many of the staff.
Alma
6
Full-Range Leadership Model/Theory
Definition: Focuses on the behavior of leaders towards the workforce in different work situations. (Marquis & Huston, 2011)
Three sub-types
Transactional
Transactions between leaders and followers
Leaders promote compliance to standard SBAR method through rewards and punishments
Transformational
Identifies needed change, inspires, and executes change
Emphasize the importance of reducing errors in patient hand-off through application of SBAR. Our goal is to enhance quality of care and thorough communication.
Laissez-faire
No standard rules
Used when nursing staff and PCTs are efficient with and advocating use of SBAR
Full Range Leadership: Promise, Momentum, Harvest
Wendy
Transactional: Promoting buy-in from nurses and PCTs through encouragement of ideas and discussion while also increasing of stakeholder support of the SBAR method
Theory should apply to what we are trying to accomplish
“this is how we plan to use this leadership style because….”
Why is this theory important for our outcome?
Using more then one theory, where is it applicable?
7
Plan
Following the three-week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of one-month with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.
At the end of the one-month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the one-month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial.
8
3 Weeks
RNs and assistive personnel to attend 1 or more in-services on SBAR handoff report
Following in-service, SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.
1-month trial
SBAR will be implemented on the unit for a trial period with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.
15 days into the trial month/ after the trial month
Nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
Post 1-month trail
Staff invited to discuss their experiences with SBAR, to share ideas to improve it
Second trial(1 – 3 months)
New SBAR form that includes select suggestions from staff will be used. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial. Then again at the end of three months.
Metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
References
Drach-Zahavy A ; Hadid N. Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift. J Adv Nurs. 2015; 71: 1135-1145
Ghosh, K., Curl, E., Goodwin, M., Morrell, P., & Guidroz, P. (2018). An Exploratory Study on how to Improve Bedside Change-of-Shift Process: Evidence from One Hospital Using Technology to Support Verbal Reporting. HICSS.
Marquis, B.L., & Huston, C. (2011). Leadership roles and management functions in nursing: Theory and application (9th ed). Lippincott, Williams, Wilkins. ISBN: 978-1-4963-4979-8
Robins, H., & Dai, F. (2015). Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care. AANA journal, 83 4, 264-8.
Stewart, Kathryn R., “SBAR, communication, and patient safety: an integrated literature review” (2016). Honors Theses. https://scholar.utc.edu/honors-theses/66
